Hospital ERs Play Vital Role in Reducing Youth Violence

Thirty minutes of counseling during an emergency room visit can decrease a young person's involvement in future violent behaviors

Researchers from the Michigan Youth Violence Prevention Center and the U-M Injury Center found that a single, structured counseling session delivered to high-risk youth by a social worker-level therapist was successful in decreasing violent aggression among participants in the two months following the study period, as well as raising their confidence that they could avoid a fight in the future. Both centers are funded by the Centers for Disease Control and Prevention.

"Violence has been the leading cause of death among urban youth for well over the past decade," said Patrick Carter, M.D. (Residency 2009), the lead author of the study and an emergency physician and assistant professor in the Injury Center. "Emergency departments are a key contact point for accessing at-risk youth in urban communities, and identifying and intervening with these youth has the potential to alter their future trajectory to one that avoids violence involvement, and thus impacts their overall health by decreasing their risk of violent injury and death."

The researchers from the School of Public Health and Medical School enrolled 409 youth from two high-risk neighborhoods in Flint, Michigan. These were young men and women ages 14 to 20 who, from October 2011 to March 2015, used the Hurley Medical Center emergency department for medical or injury-related care.

Participants in one neighborhood received the 30-minute brief intervention and a brochure of community resources. Those in the comparison neighborhood only received the brochure. Two months after the emergency department visit, those receiving the intervention reported a 10 percent lower rate of aggressive violence behaviors than youth who did not receive the counseling, and reported a positive increase of almost 8 percent in their confidence level at avoiding fighting behaviors.

The counseling session focused on strengthening their personal goals; delivering tailored feedback on violence behaviors; conducting exercises designed to explore the benefits of avoiding violence behaviors; conducting role-playing scenarios to develop skills in anger management, conflict resolution and strategies for refusing to carry weapons and avoiding violent situations; and developing strategies to make lasting behavioral changes.

The youth were asked about their violence behaviors, as well as how confident they were after the intervention that they could stay out of fights, understand another person's point of view, and calm down when they were mad.

"The type of brief intervention and counseling approach utilized in this study has been shown to be effective with adolescents in a number of other areas, including decreasing underage drinking among at-risk adolescents and for decreasing violent behaviors among youth who are already engaged in fighting and alcohol use," Carter said. "We have built on these prior successes to construct an intervention that can be applied universally for decreasing violence among youth seeking ED care who live in high-risk communities.

"This type of counseling emphasizes a nonjudgmental and nonconfrontational approach that has also been shown to work well with adolescent youth populations who value independence and who are unlikely to make changes in response to more directive authoritative approaches."

The Michigan Youth Violence Prevention Center, led by study co-authors Marc Zimmerman, Ph.D., professor of health behavior, health education and of psychology; and Rebecca Cunningham, M.D. (Residency 1999), professor of emergency medicine and director of the Injury Research Center, has worked with Flint community partners since 2011 to develop and test the efficacy of a comprehensive youth violence prevention program that addresses violence risk at multiple levels within the community. The current study reports on one of the six interventions tested in the intervention neighborhood to decrease youth violence.

Other interventions delivered as a part of this program involved social interactions, such as parent-child mentoring, and addressing community and environmental factors, including community policing and initiatives to clean up neighborhoods by adding garden spaces. Another intervention tested a youth empowerment curriculum to enhance positive youth development among younger adolescents.

Carter said this type of violence intervention at the hospital emergency department is the first to test a universal approach, wherein all youth from a high-risk neighborhood receive the intervention as a means of decreasing violence throughout the community. Additionally, it may be a good option for many of the young people who aren't exposed to the other violence reduction programs within their community.

"Many youth involved in violence do not regularly attend school or receive regular primary care," he said. "The ED is an important location where we can interact with them and address issues such as violence that may be going on in their lives.

"Further, if they are seeking care for a medical issue related to their violence — which is not a requirement to receive the intervention — they may be more reflective on the events that led up to that visit and thus the visit can serve as a teachable moment."

The study is published online in the journal Academic Emergency Medicine. Other U-M authors: Maureen Walton, Ph.D., associate professor of psychiatry; Stephen Chermack, Ph.D., professor psychiatry and chief of mental health service at the VA Ann Arbor Healthcare System; and Jessica Roche, research specialist at the U-M Injury Center.